Coding for Pelvic Reconstruction Surgery

Presenter: Melanie Witt, RN, CPC, COBGC, MA

Sponsored by Boston Scientific Corporation

WH-112905-AA 1 of 57 24OCT2012 Important Information

 The purpose of this presentation is to provide you with general information and key considerations related to pelvic reconstruction procedures in which Boston Scientific products are used in a manner consistent with their labeled indications.

 Caution: Federal (U.S.) law restricts these devices to sale by or on the order of a physician. Please refer to package insert provided with the product for complete Indications for Use, Contraindications, Warnings, Precautions, Adverse Events and Instructions.

 Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA-approved label.

 CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

WH-112905-AA 2 of 57 24OCT2012  Ms. Witt provides coding and reimbursement assistance to Boston Scientific Corporation relating to their products for female genitourinary conditions.

 The opinions and recommendations expressed in this presentation are those of the presenter and do not necessarily reflect those of Boston Scientific.

See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 3 of 57 24OCT2012  Select appropriate CPT® Codes for each type of repair

 Understand the role of documentation to ensure fair and timely reimbursement

 Select appropriate diagnostic linkages in support of procedures performed

 Understand how payer billing rules can impact reimbursement

 Effectively report surgical complications

CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 4 of 57 24OCT2012 See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 5 of 57 24OCT2012  Documentation of

◦ What you did

◦ How you did it

◦ Why you did it

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 6 of 57 24OCT2012  An improperly filed claim for payment automatically adds another 30 days before you receive payment ◦ It could be your fault, not the coders

 Large surgical practices can lose around 20% in revenue due to improperly coded claims ◦ Smaller practices generally lose less revenue due to less volume of claims and more time by staff to investigate correct coding  This still assumes well trained coding/billing staff

See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 7 of 57 24OCT2012  The operative note represents the most important document for justification of reimbursement for surgical services

 Consider it a stand-alone document

 Surgeons should reassess the operative note as a billing document and provide the information necessary to expedite reimbursement

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 8 of 57 24OCT2012  Important elements ◦ Pre- and postoperative diagnoses

◦ Procedure performed  Try and use CPT® Code terminology

◦ Indications statement

◦ Findings statement

◦ Description of each procedure performed in enough detail to support billing  If procedure is very difficult spend some time describing it and indicate time in comparison to normal time

◦ Sponge count & patient status

CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 9 of 57 24OCT2012  Know your payers and their policies ◦ Coding can’t fix a bad contract ◦ Negotiate for the things you want

 Work with your coders and billers ◦ Be available and open for questions ◦ Plan regular meetings to discuss problems ◦ Make sure someone is watching denials and payer contracted payment amounts

 Be prepared to appeal denials – every time when right is on your side ◦ May require writing letters or contacting the payer’s medical director to resolve issues

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 10 of 57 24OCT2012 See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 11 of 57 24OCT2012  Anterior colporrhaphy— CPT® Code 57240:

◦ Usually performed for midline cystocele or cystourethrocele

◦ Basic description: open anterior wall, plicate excess tissue, suture closed, cut off excess

◦ Includes repair of urethrocele if performed

◦ Repairs a lateral defect

◦ All approaches include cystocele repair (anterior colporrhaphy)

◦ Reattaches the lateral vagina to the ATFP

◦ All CPT® Codes for this repair involve entering the space of Retzius and using sutures to make the attachment  Abdominal (CPT Code 57284)  Vaginal (CPT Code 57285)  Laparoscopic (CPT Code 57423)

CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 13 of 57 24OCT2012  Rectocele repair ◦ Without posterior colporrhaphy: CPT® Code 45560  Documentation will show rectal plication  Normally performed by a general surgeon for fecal incontinence ◦ With posterior colporrhaphy: CPT Code 57250  Includes perineorrhaphy  Open the posterior vaginal wall, plicate thickened tissue, suture to close defect, cut off excess

 Combined Procedures ◦ Each includes perineorrhaphy ◦ A&P: CPT Code 57260 ◦ A&P & enterocele repair: CPT Code 57265

 Can be repaired at the time of a vaginal hysterectomy ◦ Report inclusive codes only  CPT Codes 58263, 58270, 58280, 58292, 58294

 Can be repaired at the time of colpopexy ◦ McCall culdoplasty to reduce the enterocele (CPT Code 57283) per ACOG ◦ Do not bill for both an enterocele repair and colpopexy at the same operative session

CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 15 of 57 24OCT2012  Colpopexy: ◦ Attach vaginal vault to a supporting structure usually using mesh  Use of mesh is not reported separately

◦ Laparoscopic—CPT® Code 57425 ◦ Abdominal—CPT Code 57280 ◦ Vaginal:  Sacrospinous or iliococcygeus ligament—CPT Code 57282  Uterosacral or levator myorrhaphy— CPT Code 57283

◦ Documentation of vault prolapse is required by most payers

CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 16 of 57 24OCT2012  Main rationale is to provide support to the already attenuated or absent connective pelvic floor tissues that have failed

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 17 of 57 24OCT2012  Vaginal mesh kits facilitate physician placement and may reduce operative time. ◦ Mesh can be additionally cut or trimmed in OR to fit the patient

 Physicians often refer to procedures by the name of the product they use ◦ E.g., Uphold® System, Elevate® Prolapse Repair System, Repliform® Matrix, etc. ◦ These product names will not get the claim coded properly ◦ It is what the surgeon documents that determines the code

◦ The product is named by the company that developed it  May include one product or a combination of products within a single package (Kit/System) that includes special tools to accomplish an implants placement (introducers, obturators, needles, etc.)  Not all products are the same. Product selection is based on physician preference and desired outcomes for the patient

Caution: Federal (U.S.) law restricts these devices to sale by or on the order of a physician. See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 18 of 57 24OCT2012  You report the CPT® Code that best fits the repair type ◦ Anterior repair  Note, even though some mesh systems may anchor the mesh at the arcus tendineus, this is not the same as the work for the paravaginal codes developed by CPT ◦ Posterior repair ◦ Vaginal vault repair

 Mesh may be bundled by the payer without establishing medical need for the augmentation to the anterior or posterior wall

Uphold® Vaginal Anterior wall, and Sacrospinous Yes, with Support System vaginal vault ligament, with documented repair overlay of anterior pubocervical compartment fascia weakness

Pinnacle® Posterior wall Sacrospinous Yes, if rectovaginal Posterior Pelvic repair ligament fascia weakness is Floor Repair Kit documented

Elevate® Prolapse Anterior wall, Sacrospinous Yes, if Repair System posterior wall and ligament and/or pubocervical or vault repair obturator internus rectovaginal fascia muscle weakness is documented

Caution: Federal (U.S.) law restricts these devices to sale by or on the order of a physician. See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 20 of 57 24OCT2012 See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 21 of 57 24OCT2012  Purpose ◦ To provide medical indication for claim payment ◦ Data collection

 The provider assigns the diagnosis, not the coder

 Link each procedure or service to it’s own diagnosis

 Always code to the highest level of specificity ◦ An unspecified code can cause a claim denial or delay of payment, especially for surgical cases

See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 22 of 57 24OCT2012  Payers reimburse for medically indicated procedures ◦ The diagnosis codes reported establish medical indication and need to be as specific as possible

 Each surgical procedure performed must be supported by at least 1 diagnostic code that indicates the reason it is necessary for this patient

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 23 of 57 24OCT2012 Uncodeable Why? Without More Info Uterine prolapse Is it only uterine prolapse or is there vaginal wall prolapse in addition?

Genital prolapse What is prolapsing?

Uterovaginal It is incomplete or complete prolapse? prolapse Pelvic relaxation Results from lax ligaments, fascia, and muscles supporting the pelvic organs (pelvic floor). So which ones? Pelvic floor Refers to a wide range of problems that occur when the dysfunction muscles of the pelvic floor are weak or tight. So what is the patient’s specific problem that requires surgery to fix? Urogenital prolapse Can refer to displacement of the uterus, the bladder and the rectum with consequent dislocation of the vaginal walls. So which one(s)?

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 24 of 57 24OCT2012 Uncodeable Why? Without More Info Significant pelvic What is significant? Which areas are prolapsing? prolapse

Pelvic organ Which ones? How bad? prolapse Vaginal vault And does she still have her uterus? prolapse Vaginal wall prolapse Anterior or posterior wall?

Recurrent distal Was it midline or lateral? cystocele

At risk for SUI Possibly a V code. She either has it or she does not.

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 25 of 57 24OCT2012  Paravaginal defect ◦ 618.02, lateral cystocele repair

 Colpopexy ◦ 618.09, Vaginal vault prolapse with uterus in place ◦ 618.2-618.4, Vaginal vault prolapse with uterine prolapse

◦ 618.5, Vaginal vault prolapse after

hysterectomy

 McCall, Halban, ◦ 618.6, Vaginal enterocele Moschcowitz culdoplasties

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 26 of 57 24OCT2012  Anterior repair ◦ 618.01, Midline defect ◦ 618.2-618.4, With uterine prolapse

◦ 618.04, Rectocele  Posterior repair ◦ 618.2-618.4, With uterine prolapse

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 27 of 57 24OCT2012 See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 28 of 57 24OCT2012  AMA’s rationale for adding CPT® Code 57267 ◦ Native tissues are determined to be weak and inadequate for repair with reconstructive procedures performed for the anterior and posterior compartments of the vagina

◦ The MD decides to insert an intervening prosthetic material (e.g., autograft, allograft, xenograft, synthetic)

◦ The physician work includes insertion of prosthetic material, extra sutures as needed, and mesh sizing  This work is distinct from the physician work involved in performing the primary pelvic floor defect repair(s) which primarily involves re-approximation of pelvic fascial tissues only

CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 29 of 57 24OCT2012  CPT® Code 57267 can only be reported when performing a vaginal approach repair ◦ CPT codes 45560, 57240-57265, 57285 only  Add-on mesh code is not reported with laparoscopic or abdominal paravaginal repairs, or colpopexy procedures

 Bill once per vaginal wall repair ◦ Anterior x 1, posterior x 1

 Remember that medical need must be documented to report ◦ Weakened pubocervical tissue (618.81) and/or ◦ Weakened rectovaginal tissue (618.82)

CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 30 of 57 24OCT2012  Does not establish medical need ◦ “Discussed with patient use of mesh and she consented” ◦ “Mesh was placed” ◦ “anterior repair with mesh”

 Does establish medical need ◦ “Patient’s native tissues were friable so decision was made to augment repair with mesh” ◦ Findings: “Attenuated rectovaginal tissue” ◦ “Pubocervical fascia was atrophic and required mesh repair”

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 31 of 57 24OCT2012  Cystoscopy is a frequently performed procedure after reconstructive surgery ◦ Done to ensure bladder is not compromised by sutures, needles or mesh used in the repair  A procedure done by the surgeon to check his work is always included in the surgical procedure

 Can only be billed for a documented pre- existing condition that must be investigated at the time of the surgery

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 32 of 57 24OCT2012  “I then performed cystoscopy with above mentioned findings.” ◦ Findings: “There was no trauma to the bladder as seen on cystoscopy at the conclusion of the procedure. Both ureters were seen to efflux clear indigo carmine stained urine.”

 “Cystoscopy was then done. There is clear urine effluxing from both ureters at the conclusion of the procedure. There was no trauma to the bladder or aberrant suture material present. We also looked at the urethrovesical angle and it coarcted nicely.”

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 33 of 57 24OCT2012  Indications statement: On exam, she was noted to have a grade 3 cystocele, grade 2 uterine prolapse, and grade 1 rectocele. She also demonstrated urethral hypermobility and perineal laxity. Urodynamic testing revealed borderline bladder capacity without objective evidence of stress incontinence with the prolapse reduced. Her symptoms were more consistent with overactive bladder ◦ Given the patient's symptoms of urinary frequency discussed above, attention was turned to the cystourethroscopy. A 70-degree cystoscopic telescope was inserted into the bladder lumen which was filled in a retrograde fashion. The bladder lumen was carefully visualized in its entirety. No bladder injury was noted. The trigone and both ureteral orifices were identified. The patient was given 5 mL of IV indigo carmine and both ureteral orifices were noted to spill dye confirming ureteral patency. The urethra was then visualized upon extraction of the cystoscope and found to be normal. Bladder lumen appeared normal without trabeculations, foreign body, masses/lesions, or abnormal vascular patterns. Bilateral ureteral patency was reconfirmed. The urethra was normal upon extraction of cystourethroscope.

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 34 of 57 24OCT2012  Payers do not reimburse for procedures that fix a problem not yet in evidence

◦ Many physicians believe that prophylactic repair will avoid future surgery for the patient

 The payer is not interested in this argument, and  You cannot fix a coverage problem with coding  Reporting a diagnostic condition not documented to get this type of procedure paid can be considered fraud

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 35 of 57 24OCT2012  Coded the same as laparoscopic procedures

◦ No additional physician reimbursement for using robot, but you can report that you used the robot (e.g., robot-assistance sacrocolpopexy)

 CPT® Code 57425, laparoscopic colpopexy  HCPCS Code S2900, Surgical techniques requiring use of robotic surgical system

CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 36 of 57 24OCT2012  Dx 629.31 (mesh erosion)  Revision of graft to repair or remove ◦ CPT® Code 57295 (vaginal approach)  Caution! CPT Code 57295 has 13.13 RVUs and is appropriate only for a facility site of service, not office  Office removal of eroding mesh using forceps or scissors is CPT Code 58999 only  Comparison codes can be incision and removal of foreign body  CPT Codes 10120 (3.45 RVUs), or 10121 (6.68 RVUs) ◦ CPT Code 57296 (abdominal approach) ◦ CPT Code 57426 (laparoscopic approach) ◦ Modifier -78 if return to OR in global period

CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 37 of 57 24OCT2012  You can bill for unexpected complications of the surgery that do not result in a return to the OR….maybe  “I can’t pee” would not be unexpected for many uro/gyn procedures  Wound dehiscence or infection would be unexpected

 Medicare always requires a return to the hospital OR to bill for complications

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 38 of 57 24OCT2012 Results from case studies are not predictive of results in other cases. Results in other cases may vary. See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 39 of 57 24OCT2012  28 y/o g5 with a symptomatic vaginal bulge who desired permanent correction. She had documented stress and urge urine loss. She also had symptoms of interstitial cystitis.

 She was consented for and had a vaginal hysterectomy, BSO, anterior and posterior repair with synthetic graft kit, enterocele repair, perineal body reconstruction, suburethral sling, and cystoscopy.

See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 40 of 57 24OCT2012  CPT® Code 58260, vaginal hysterectomy ◦ linked to 618.3 (uterovaginal prolapse, complete)  Line item was paid at 100% of allowable

 CPT Code 57265-51, combined anterior/posterior repair with enterocele repair ◦ linked to 618.01 (Cystocele, midline), 618.04 (Rectocele) and 625.6 (Stress incontinence, female)  Line item was paid at 50% of allowable

CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 41 of 57 24OCT2012  CPT® Code 57267 x 2, insertion of add-on mesh ◦ linked to 625.6 (stress incontinence, female)  Line item was denied due to ICD9/procedure code mismatch

 CPT Code 52000-51, cystoscopy ◦ linked to 625.6 (stress incontinence, female)  line item was denied as bundled

 Which Dx for incontinence is documented?

 Is perineal body repair included?

 Is cystoscopy diagnostic and separate from routine surgical care?

See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 43 of 57 24OCT2012  CPT® Code 57265, combined A&P repair with enterocele repair ◦ linked to 618.3 (uterovaginal prolapse, complete ) - 27.15 RVUs

 CPT Code 58260-51, vaginal hysterectomy ◦ linked to 618.3 (uterovaginal prolapse, complete ) - 24.69 RVUs

 CPT Code 57288, sling procedure ◦ linked to 788.33 (mixed incontinence, urge and stress - male/female) - 21.16 RVUs

 CPT Code 57283-51, uterosacral colpopexy (includes enterocele repair) ◦ linked to 618.3 (uterovaginal prolapse, complete) - 20.59 RVUs

 CPT Code 57267, add-on mesh for posterior repair ◦ linked to 681.82 - 7.67 RVUs

 CPT® Code 58260 vaginal  CPT Code 57265 combined hysterectomy – 24.69 RVUs A&P repair with enterocele  CPT Code 57265 combined repair – 27.15 RVUs A&P repair with enterocele  CPT Code 58260 vaginal repair – 50% of 27.15 RVUs hysterectomy – 50% of 24.69 RVUs Total RVUs: 38.27 RVUs  CPT Code 57288 sling procedure – 50% of 21.16 RVUs

 CPT Code 57283 uterosacral  CPT Code 57265 combined colpopexy (includes enterocele A&P repair with enterocele repair) – 50% of 20.59 RVUs repair – 27.15 RVUs  CPT Code 57267 insertion of  CPT Code 58260 vaginal add-on mesh– 7.67 RVUs hysterectomy – 50% of 24.69 RVUs Total RVUs: 68.05 RVUs

Total RVUs: 39.50 RVUs 45 of 57 45 CPT Copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. See important notes on the uses and limitations of this information on slide 2.  Stage III uterine prolapse, Urodynamic stress incontinence, vaginal outlet relaxation, cystocele

 Surgeon performs bilateral anterior sacrospinous fixation with Uphold® Mesh, anterior repair with Uphold Mesh, TVT- obturator sling system, perineorrhaphy, and cystoscopy

Products are labeled for individual use and concomitant repairs are at the discretion of the physician. See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 46 of 57 24OCT2012  Anterior pubocervical tissue weakness is not documented

 There is no indication of need for a diagnostic cystoscopy for any reason other than the surgeon checking his work

See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 47 of 57 24OCT2012  CPT® Code 57288 sling procedure ◦ linked to 625.6 - 21.16 RVUs

 CPT Code 57240-51 anterior repair ◦ linked to 618.3  50% of 19.80 RVUs

 CPT Code 57282-51 vaginal colpopexy ◦ linked to 618.3  50% of 14.93 RVUs

 CPT Code 56810-51 ◦ linked to 618.89  50% of 7.74 RVUs

Total RVUs: 42.40 RVUs

WH-112905-AA 48 of 57 24OCT2012 See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 49 of 57 24OCT2012 ICD-9-CM ICD-10-CM 618.00, Unspecified prolapse of No ICD10 equivalent vaginal walls 618.01, Cystocele, midline N81.10, Cystocele, unspecified N81.11, Cystocele, midline 618.02, Cystocele, lateral N81.12, Cystocele, lateral Includes cystourethrocele 618.03, Urethrocele N81.0, Urethrocele only 618.04, Rectocele N81.6, Rectocele 618.05, Perineocele N81.81, Perineocele 618.09, Other prolapse (e.g, N81.89, Other female genital cystourethrocele) prolapse

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 50 of 57 24OCT2012 ICD-9-CM ICD-10-CM 618.2, uterovaginal prolapse, N81.2, incomplete uterovaginal incomplete prolapse Includes 1st & 2nd degree uterine prolapse, cervical prolapse NOS, uterine prolapse with any form of vaginal wall prolapse 618.3, uterovaginal prolapse, N81.3, complete uterovaginal complete prolapse 3rd degree uterine prolapse, procidentia NOS, uterine prolapse with any form of vaginal wall prolapse 618.4, uterovaginal prolapse, N81.4, uterovaginal prolapse, unspecified unspecified

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 51 of 57 24OCT2012 ICD-9-CM ICD-10-CM 618.1, Uterine prolapse only No ICD10 equivalent 618.5, Vaginal vault prolapse N99.3, Prolapse of vaginal vault after hysterectomy after hysterectomy

618.6, Vaginal enterocele N81.5, Vaginal enterocele Excludes enterocele with uterine prolapse (N81.2-N81.4)

618.7, Old laceration of pelvic N81.85, Other female genital floor muscles prolapse Includes deficient perineum

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 52 of 57 24OCT2012 ICD-9-CM ICD-10-CM 618.81, Incompetence or N81.82, Incompetence or weakening of pubocervical weakening of pubocervical tissue tissue 618.82, Incompetence or N81.83, Incompetence or weakening of rectovaginal tissue weakening of rectovaginal tissue 618.83, Pelvic muscle wasting N81.84, Pelvic muscle wasting 618.84, Cervical stump prolapse N81.85, Cervical stump prolapse 618.89, Other specified genital N81.89, Other female genital prolapse prolapse 618.9, Unspecified genital N81.9, Female genital prolapse, prolapse unspecified

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 53 of 57 24OCT2012 See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 54 of 57 24OCT2012  American Medical Association, Current Procedural Terminology, Professional Edition, 2011

 International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), 10/01/11

 ICD-9-CM Official Guidelines for Coding and Reporting, 10/01/11

 Centers for Medicare and Medicaid Services (CMS), National Correct Coding Initiative, Version 16.0

 Urogynecology and Reconstructive Pelvic Surgery, Third Edition, Mark D. Walters, Mickey M. Karram

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 55 of 57 24OCT2012  Boston Scientific ◦ www.bostonscientific.com ◦ www.bostonscientific.com/reimbursement ◦ www.pelvic-floor-institute.com

 American Medical Systems ◦ www.americanmedicalsystems.com/womens_health.html

 Gynecare ◦ www.clinicalexpertise.com/clinical-focus/pelvic-organ- prolapse

See important notes on the uses and limitations of this information on slide 2.

WH-112905-AA 56 of 57 24OCT2012 See important notes on the uses and limitations of this information on slide 2. Uphold and Pinnacle are registered trademarks of Boston Scientific Corporation or its affiliates. All other trademarks are property of their respective owners.